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Am J Perinatol 2022; 39(13): 1375-1382
DOI: 10.1055/a-1799-5582
SMFM Fellowship Series Article

Enhanced Recovery after Surgery Protocol to Improve Racial and Ethnic Disparities in Postcesarean Pain Management

Laura Felder 
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia
,
Connie D. Cao
2   Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia
,
Casey Konys
3   Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia
,
Nimali Weerasooriya
2   Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia
,
Rebecca Mercier
2   Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia
,
Vincenzo Berghella
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia
,
Sandra Dayaratna
2   Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia
› Author Affiliations Funding None.
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Abstract

Objective The objective of this study was to assess the efficacy of an enhanced recovery after surgery (ERAS) protocol and determine its effect on racial/ethnic disparities in postcesarean pain management.

Study Design We performed an institutional review board-approved retrospective cohort study of scheduled cesarean deliveries before and after ERAS implementation at a single urban academic institution. Pre-ERAS, all analgesic medications were given postoperatively on patient request. The ERAS protocol included preoperative acetaminophen and celecoxib. Postoperatively, patients received scheduled nonsteroidal anti-inflammatory drugs and acetaminophen. Oral oxycodone was available as needed, and opioid patient-controlled analgesia was eliminated from the standard order set. The primary outcome was total opioid use in the first 48 hours after cesarean, pre- and post-ERAS, reported in total milliequivalents of intravenous morphine (MME). A secondary analysis of opioid use and pain scores by racial groups was also performed. Chi-square, independent t-tests, analysis of variance, Mann–Whitney U, and Kruskal–Wallis tests were used depending on variable and data normality.

Results Pre-ERAS and post-ERAS groups included 100 women each. Post-ERAS, total opioid use in 48 hours was less (40.8 vs. 8.6 MME, p < 0.001) and visual analog scale (VAS) pain scores were lower on postoperative day 1 (POD1) and 2 (POD2) (POD1 maximum at rest: 6.7 vs. 5.3, p < 0.001). Pre-ERAS pain scores differed by race with non-Hispanic Black (NHB) patients reporting the highest mean and max VAS pain scores POD1 and POD2 (POD1, maximum VAS at rest: NHB—7.4, non-Hispanic White—6.6, Hispanic—5.8, Asian—4.4, p = 0.006). Post-ERAS, there were no differences in postoperative pain scores between groups with movement on POD1 and POD2.

Conclusion A standardized ERAS protocol for postcesarean pain decreases opioid use and may improve some racial disparities in postcesarean pain control.

Key Points

  • ERAS protocols improve postoperative pain control and lower postoperative opioid use.

  • Studies show that there are racial and ethnic disparities in postpartum pain control.

  • Protocols standardize care and may decrease the effects of provider implicit bias.

Keywords

enhanced recovery after surgery - postoperative analgesia - racial disparities

Note

Part of this manuscript was presented at the Society for Maternal-Fetal Medicine 41st Annual Pregnancy Meeting on January 29, 2021 (abstract 404).




Publication History

Received: 11 October 2021

Accepted: 11 March 2022

Accepted Manuscript online:
15 March 2022

Article published online:
31 May 2022

© 2022. Thieme. All rights reserved.

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